Mark Ross, Ph.D., FAAA, Professor Emeritus
at the University of Connecticut

All of us have had the experience of suggesting to a friend or
relative that he or she get a hearing aid, only to be told that
it was not necessary since he/she could "hear all
right"--this comment being made during a conversation in
which shouting was the only way to communicate. It is a
frustrating experience for all concerned, much more so for the
person with the hearing loss. Why, then, do people react this way
so frequently? Why is it that only about twenty percent of adults
who can potentially benefit from a hearing aid actually use one?
How can the clear evidence of a hearing loss be so continually
and, sometimes, so argumentatively denied by the affected
persons?

There is no way to help those who disclaim the severity or
presence of a hearing loss. To them, the recent developments in
hearing technology and public law are irrelevant. These people
will not accept a hearing aid, other types of hearing assistance
devices or any kind of rehabilitative measure if they deny the
existence of a hearing problem. Everybody, lay persons and
professionals alike, have explanations for this dilemma. And all
are probably correct to some degree for some people. Probably
there is no single reason, but rather a different combination of
possible ones for every hard of hearing adult who rejects
auditory assistance. In this article, I would like to explore a
few of the reasons I think are most pertinent.

Association with Age

As people get older, they begin to lose some of their sensory
and physical capabilities. The sense of hearing is one of those
that show a gradual deterioration with age. Indeed, one of the
common stereotypes of older people portray them as having
difficulty hearing, perhaps with their hands cupped behind their
ears, saying "Eh?" in a high-pitched, querulous voice.
A hearing loss doesn't happen because we have been
"bad" people or guilty of abusing our bodies in any way
(though this can cause an additional hearing loss). It is a
natural occurrence; on the positive side, it means we have lived
long enough for it to happen. Many years ago presbycusis (hearing
loss associated with aging) happened less often, simply because
fewer people lived long enough for the process to begin.

Our culture is obsessed with youth and the youthful image. To
be young is to be beautiful, mentally alert, vigorous, sexy, and
able to participate fully in the pleasures of life. Aging, on the
other hand, is associated with the converse of these images. In
our society, it implies that one is mentally and physically
desiccated, confused, fearful and dependent, and that the end of
the road is imminent. No wonder we spend fortunes on cosmetics,
plastic surgery, etc., trying to deny and camouflage the natural
concomitants of age, the goal being to look as if we were
recently dipped into a fountain of youth. I know of people well
into their 70s and 80s who reject a hearing aid because they say
it would make them look too old! What they really mean is that
the hearing aid may force them to acknowledge the reality of the
aging process. Other cultures value age and the wisdom of
experience; we disparage and mock it, viewing it as a weakness, a
personal misfortune. Trying to remain vigorous and attractive is
one thing; denying reality is something else again.

For many people, therefore, a hearing aid is an unwelcome
reminder of the aging process, their own mortality, and it is one
that they simply cannot accept. They will go to almost any
length, and sometimes they do, to deny a hearing loss, to
themselves and to other people. These are the people for whom the
most blatant cosmetic appeal ("The aid is so small that no
one can see it") falls on "deaf" ears; it is not
the size of the hearing aid, but the acknowledgment of a hearing
loss that is unacceptable.

The pity of this attitude, of course, is that while they can
refuse to wear a hearing aid or use any other acoustic prosthesis
(such as an infrared listening device in the theater), they
cannot disguise the communicative consequences of a hearing loss.
They still miss and misunderstand much everyday conversation;
their social and cultural activities gradually diminish; and
their lives become more and more constricted. Their attitude is
self-defeating: In trying to deny the reality of a hearing loss,
because of its association with aging, their conversational
partners may ascribe their confused communicative behavior to
senility--a condition most certainly associated with aging!

Hearing aids, or other hearing assistance technologies, will
not restore youth or normal hearing. Their acceptance and usage
signifies that the existence of a hearing problem has been
acknowledged and that the person is determined to do what is
necessary to help himself or herself. This simple acknowledgment
is the crucial first step in successfully coping with a hearing
loss.

Association with a New Challenge

For many other older people, the reluctance to use a hearing
aid does not really signify a denial of the aging process. They
recognize what their face in the mirror is telling them. What
prevents them from wearing a hearing aid is that it represents
change. It means learning and adapting to something different--in
this case, how to use and insert a miniature but sophisticated
electronic device. Change is the key word. As we get
older, we do get more set in our ways; learning new
material does require that extra motivation, that extra
push. It is more comfortable to stay in the rut, with the comfort
of knowing that tomorrow will be much like today. Audiologists
often hear comments reflecting this attitude from clients
(usually, though not always, the older ones): "I can't be
bothered," "It's so complicated," "I'm an old
lady (man) now," and so on. It is difficult and we
should not underestimate the effort and re-orientation that takes
place when an older person decides to wear a hearing aid. It
means that he or she is determined to rejoin the larger society
to some extent. It implies a modification of a restrictive and
unsatisfying, but adaptive, life-style that has evolved over the
years. It means, in effect, the affirmation of life, instead of
passively waiting for the inevitable end. It means new learning
and exercising one's brain cells, perhaps the most difficult
chore there is (and not just for the older person!).

There is no magic formula that I know of to convince someone
who is older to accept the challenge inherent in wearing a
hearing aid. Perhaps by conveying the belief that he or she is
valued and is of value, we can provide the motivation for the
initial effort. Follow-up procedures are important for any one
during the critical initial adjustment period, but particularly
so for the first-time hearing aid user who is older. They need to
know that someone will be there, to help them over the rough
spots, and to answer their questions patiently and with
sensitivity. Yes, it is difficult for an many older people to
accept use of a hearing aid, but this fact does not relieve us of
the responsibility to make the attempt.

Association with Disability

We know from psychological research that people with
disabilities have traditionally carried an aversive and negative
image in most societies. A hearing impairment is a disability,
one that is often associated with an entire cluster of
unfavorable characteristics, such as dementia, strangeness,
feebleminded, "dumbness" and so on. Hard of hearing
people who were born with normal hearing are likely to reflect
society's prevalent attitude toward disability. If they do,
denial of their own hearing loss is understandable; they simply
cannot reconcile the prejudices and attitudes they grew up with
and their own current status. How can they now perceive
themselves as part of a group they used to disparage, that they
thought were strange? How can they now think of themselves as one
of the "others," the outsiders of society? It is easier
to deny the hearing loss than confront themselves. Of course, as
mentioned above, this denial eventually becomes an exercise in
futility. The effects of the hearing loss cannot be hidden and
the attempts to do so soon become counterproductive and
essentially irrational. The irony of the situation is that by not
helping themselves, the "deniers" become even more
disabled in their functioning and reputation, thus exacerbating
the very situation they were trying to avoid.

The Cosmetic Focus

It is clear, then, that without a change in public attitudes
toward hearing impairment, our success in convincing people to
acknowledge their hearing loss is always going to be limited.
People with hearing losses are part of the larger public, with
attitudes toward disability in general, and hearing-impairment in
particular, that basically reflect the values of their society.
What we need are more public educational programs regarding
hearing loss and what can be done to alter its communicative and
psychosocial consequences. In an era when sophisticated
advertising in our media can "sell" anything from
products to politicians, it should not be too difficult to
minimize the denial phenomenon and the stigma associated with
hearing aid usage. Unfortunately, it seems that much of the
efforts of the hearing aid industry in this regard are basically
counterproductive and schizophrenic.

For at least forty-five years, we have been getting mixed
messages from the hearing aid industry. On the one hand, much of
its advertising emphasizes the advantages of hearing aid usage in
improving communication capabilities. On the other hand,
different advertisements stress the miniature size of their
hearing aids, or the fact that "no one need know you are
wearing one." (Forty-five years ago, hearing aid companies
advertised that they would send an inquirer information about
their products in a plain brown envelope!). The more the industry
focuses on cosmetics, on the fact that a hearing aid can be
hidden, the more powerful the subliminal message that a hearing
loss is a condition that should be hidden. I am convinced that
for every person who succumbs to the cosmetic appeal and who
purchases and wears an "invisible" hearing aid, there
are several others whose feelings of shame and reluctance to
acknowledge a hearing loss are being reinforced. At the least,
the industry is perpetuating stereotypes it has an interest in
changing, which is why I call many of its efforts
counter-productive and schizophrenic.

The professional community bears its share of responsibility
for this situation. I know audiologists who would never think of
recommending a large hearing aid, even if it embodies some
desirable features (such as a telecoil). They assume that their
clients share the public perception that a smaller, less visible
hearing aid, is more likely to be worn ( or purchased, an
important consideration in a dispensing practice). Of course
people have a right to select any size hearing aid they want, but
they also have a right to be informed about different
alternatives and the relative advantages and disadvantages of
each. Some consumers will select function as their primary
criterion in a hearing aid. It is this group that can help change
public attitudes toward hearing loss. Simply by selecting hearing
aids based on function and not cosmetics, by using visible
assistive devices (such as infra-red receivers in a theater),
these people convey the message that a hearing loss is not a
personal disgrace which must be camouflaged at all cost. Their
lives demonstrate that they are not diminished in stature, in
self-esteem or the esteem of their loved one or their community,
by virtue of their hearing loss. In the long run, it will be the
example set by these people that will make the greatest
difference in public acceptance of hearing loss and hearing aids.

High Cost

Hearing aids are expensive. Two are almost twice as expensive
as one. Unlike computers and other electronic gadgets, their
absolute cost is increasing year by year. New digital hearing
aids may cost $3,500 each. This is not a negligible
consideration, no matter how much dispensers may minimize its
importance to prospective hearing aid user. The evidence from a
number of surveys points to the expense of a hearing aid as a
significant, though not necessarily a determining, factor in the
purchase of a hearing aid. Cost will be a more significant factor
in the acceptance of a binaural hearing aid fitting. Because of
the additional expense, some people will opt for one hearing aid,
although audiologically there may be a clear listening advantage
for two.

There's not much we can do about the cost of hearing aids.
They are expensive and are likely to remain so for the
foreseeable future. What has to be communicated to prospective
users is the life-changing possibilities of improved hearing, so
they can weigh that value against the financial expense. Ensuring
the availability of a supervised trial program can help consumers
make this kind of decision. Hopefully, more public and private
health insurance programs will be covering more of the cost of
hearing aids and thus reduce the total burden for individuals.

Unrealistic Expectations

Everybody, it seems, has a friend or a relative who has had an
unsuccessful experience with hearing aids, and is quite vocal
about it. Many of these people, and there are too many of them,
discourage potential hearing aid candidates from trying one,
since they "know" that hearing aids are useless. Their
attitude plays right into the usual reluctance to accept
amplification. We should keep in mind, however, the fact that the
"failures" would not have tried a hearing aid in the
first place if they did not have an evident hearing problem (to
their family and friends, if not to them). It is quite possible
that they were ill-fit or poorly counseled, and this happens all
too often, but it is also possible that they went into the
hearing aid experience with high and unrealistic expectations.

If one expects too much, one is sure to be disappointed. A
hearing aid will not restore normal hearing. Sometimes it seems
that a new user, after fighting the necessity of wearing a
hearing aid for years, expects that his or her new aid will
completely solve all previous listening problems. A hearing aid
does not work that way. It is an aid, not an ear replacement.
When listening difficulties still occur, when one's own voice
sounds strange and "stuffy," when one is suddenly aware
of a world of strange noises, when some loud sounds actually
cause pain and discomfort, it is easy to get discouraged and
discard the hearing aid. Many of these problems can be
ameliorated with audiological assistance; some take time to get
used to, but can be lived with; and other problems will remain.
The point is that one must enter into the hearing aid experience
with realistic expectations. Does the aid offer sufficient
listening advantages in important communicative situation?
Perhaps there are just one or two such situations, but if these
are crucial then the hearing aid is necessary. Hearing aids are
too expensive, and too potentially helpful, to be placed in
dresser drawers rather than in people's ears.

Acknowledgment:

The preparation of this paper was supported in part by Grant
#H133E30015 from the U.S. Department of Education, National
Institute of Disability Rehabilitation Research to the Lexington
Center.